[Show abstract][Hide abstract] ABSTRACT: Background
Mobile health (mhealth) has emerged as a powerful resource in the medical armamentarium against human immunodeficiency virus (HIV) infection. We sought to determine among adult caregivers of HIV-exposed/infected children; the extent of mobile phone ownership, the ability to communicate in Cameroon¿s national official languages (NOL), and the refusal to receive such reminders.Methods
We conducted a pre-trial analysis of potentials participants of the MORE CARE trial. MORE CARE took place from January through March 2013 in three geographic locations in Cameroon. We included caregivers aged 18 years or older. Written communication was assessed by the ability to read and understand information presented in the consent form. Verbal communication was assessed during a two-way conversation and in a discussion about HIV infection. A question about mobile phone ownership and another about refusal to receive reminders via mobile phone were phrased to allow ¿Yes¿ or ¿No¿ as the only possible reply. A p <0.05 was considered statistically significant.ResultsWe enrolled 301 caregivers of HIV-exposed/infected children from rural (n=119), semi-urban (n=142) and urban (n=40) areas of Cameroon. The mean caregiver age was 42.9 years (SD 13.4) and 85% were women. A fifth of our study population overall had at least one of the three obstacles to mobile phone reminders. By region, 39.5% in rural, 6.3% in semi-urban, and 7.5% in urban setting had at least one obstacle, with significant differences between the rural and urban settings (p<0.001) and the rural and semi-urban settings (p<0.001). The acceptability of SMS was 96.3% and of mobile phone calls 96% (p =0.054). The ability to communicate in NOL orally was 89.7% and 84.4% in writing (p=0.052). Mobile phone ownership (p<0.001; p=0.03) and the ability to communicate in an NOL orally (p<0.001; p=0.002) or in writing (both p<0.001), were significantly lower in rural compared to semi-urban and urban settings respectively.Conclusions
The use of mHealth was limited in about one fifth of our population. The greatest obstacle was the inability to use oral or written NOL, followed by non-ownership of a mobile phone. These impediments were higher in a rural setting as compared to urban or semi-urban areas.
BMC Health Services Research 10/2014; 14(1):523. · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Minor species of the Candida albicans complex may cause overestimation of the epidemiology of C. albicans, and misidentifications could mask their implication in human pathology. Authors determined the occurrence of minor species of the C. albicans complex (C. africana, C. dubliniensis and C. stellatoidea) among Yaoundé HIV-infected patients, Cameroon. Stool, vaginal discharge, urine and oropharyngeal samples were analysed by mycological diagnosis. Isolates were identified by conventional methods and mass spectrometry (MS; carried out by the matrix-assisted laser desorption–ionisation time-of-flight MS protocol). Candida albicans isolates were thereafter submitted to the PCR amplification of the Hwp1 gene. The susceptibility of isolates to antifungal drugs was tested using the Clinical and Laboratory Standards Institute M27-A3 protocol. From 115 C. albicans obtained isolates, neither C. dubliniensis nor C. stellatoidea was observed; two strains of C. africana (422PV and 448PV) were identified by PCR electrophoretic profiles at 700 bp. These two C. africana strains were vaginal isolates. The isolate 448PV was resistant to ketoconazole at the minimal inhibitory concentration of 2 μg ml−1, and showed reduced susceptibility to amphotericin B at 1 μg ml−1. This first report on C. africana occurrence in Cameroon brings clues for the understanding of the global epidemiology of this yeast as well as that of minor species of the C. albicans complex.
[Show abstract][Hide abstract] ABSTRACT: Mobile phone text messaging has been shown to improve adherence to antiretroviral therapy and to improve communication between patients and health care workers. It is unclear which strategies are most appropriate for scaling up text messaging programmes. We sought to investigate community acceptability and readiness for ownership (community members designing, sending and receiving text messages) of a text message programme among a community of clients living with human immunodeficiency virus (HIV) in Yaounde, Cameroon and to develop a framework for implementation.
BMC Health Services Research 09/2014; 14(1):441. · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Missed scheduled HIV appointments lead to increased mortality, resistance to antiretroviral therapy, and suboptimum virological response. We aimed to assess whether reminders sent to carers by text message, mobile phone call, or concomitant text message and mobile phone call increase attendance at medical appointments for HIV care in a population of children infected with or exposed to HIV in Cameroon. We also aimed to ascertain the most cost-effective method of mobile-phone-based reminder.
MORE CARE was a multicentre, single-blind, factorial, randomised controlled trial in urban, semi-urban, and rural settings in Cameroon. Carers of children who were infected with or had been exposed to HIV were randomly assigned electronically in blocks of four and allocated (1:1:1:1) sequentially to receive a text message and a call, a text message only, a call only, or no reminder (control). Investigators were masked to group assignment. Text messages were sent and calls made 2 or 3 days before a scheduled follow-up appointment. The primary outcomes were efficacy (the proportion of patients attending a previously scheduled appointment) and efficiency (attendance/[measures of staff working time × cost of the reminders]), as a measure of cost-effectiveness. The primary analysis was by intention to treat. This study is registered with the Pan African Clinical Trials Register, number PACTR201304000528276.
The study took place between Jan 28 and May 24, 2013. We randomly assigned 242 adult—child (carer—patient) pairs into four groups: text message plus call (n=61), call (n=60), text message (n=60), and control (n=61). 54 participants (89%) in the text message plus call group, 51 (85%) in the call group, 45 (75%) in the text message group, and 31 (51%) in the control group attended their scheduled appointment. Compared with control, the odds ratios for improvement in the primary efficacy outcome were 7·5 (95% CI 2·9—19·0; p<0·0001) for text message plus call, 5·5 (2·3—13·1; p=0·0002) for call, and 2·9 (1·3—6·3; p=0·012) for text message. No significant differences were seen in comparisons of the three intervention groups with each other, and there was no synergism between text messages and calls. For the primary efficiency outcome, the mean difference for text message versus text message plus call was 1·5 (95% CI 0·7 to 2·4; p=0·002), for call versus text message plus call was 1·2 (0·7 to 1·6; p<0·0001), and for call versus text message was 0·4 (−1·3 to 0·6; p=0·47).
Mobile-phone-based reminders of scheduled HIV appointments for carers of paediatric patients in low-resource settings can increase attendance. The most effective method of reminder was text message plus phone call, but text messaging alone was the most efficient (ie, cost-effective) method.
No external funding.
The Lancet Infectious Diseases 06/2014; · 19.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Missed scheduled HIV appointments lead to increased mortality, resistance to antiretroviral therapy, and suboptimum virological response. We aimed to assess whether reminders sent to carers by text message, mobile phone call, or concomitant text message and mobile phone call increase attendance at medical appointments for HIV care in a population of children infected with or exposed to HIV in Cameroon. We also aimed to ascertain the most cost-effective method of mobile-phone-based reminder.
The Lancet Infectious Diseases 06/2014; · 19.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives
The emergence of HIV drug resistance is a crucial issue in Africa, where second-line antiretroviral therapy (ART) is limited, expensive and complex. We assessed the association between adherence patterns and resistance emergence over time, using an adherence measure that distinguishes low adherence from treatment interruptions, in rural Cameroon. Methods
We performed a cohort study among patients receiving nonnucleoside reverse transcriptase inhibitor (NNRTI)-based ART in nine district hospitals, using data from the Stratall trial (2006−2010). Genotypic mutations associated with antiretroviral drug resistance were assessed when 6-monthly HIV viral loads were > 5000 HIV-1 RNA copies/mL. ART adherence data were collected using face-to-face questionnaires. Combined indicators of early (1−3 months) and late (6 months to t − 1; t is the time point when the resistance had been detected) adherence were constructed. Multivariate logistic regression and Cox models were used to assess the association between adherence patterns and early (at 6 months) and late (after 6 months) resistance emergence, respectively. ResultsAmong 456 participants (71% women; median age 37 years), 45 developed HIV drug resistance (18 early and 27 late). Early low adherence (< 80%) and treatment interruptions (> 2 days) were associated with early resistance [adjusted odds ratio (95% confidence interval) 8.51 (1.30–55.61) and 5.25 (1.45–18.95), respectively]. Early treatment interruptions were also associated with late resistance [adjusted hazard ratio (95% confidence interval) 3.72 (1.27–10.92)]. Conclusions
The emergence of HIV drug resistance on first-line NNRTI-based regimens was associated with different patterns of adherence over time. Ensuring optimal early adherence through specific interventions, adequate management of drug stocks, and viral load monitoring is a clinical and public health priority in Africa.
[Show abstract][Hide abstract] ABSTRACT: In Cameroon, only two-thirds of children with HIV exposure or infection receive appropriate HIV-directed medical care. Mortality, antiretroviral therapy resistance and suboptimal virological response are strongly related to missed opportunities for treatment, and, more specifically, to skipped scheduled medical appointments. The present trial, MORE CARE (Mobile Reminders for Cameroonian Children Requiring HIV Care) seeks to determine if reminders sent by text message (SMS), phone call, or concomitant SMS and phone calls most increase the presence at medical appointments of HIV-infected or -exposed children (efficacy), and which is the most efficient related to working time and financial cost (efficiency).
We will carry out a multicenter single-blind, randomized, factorial controlled trial. A randomization list will be electronically generated using random block sizes. Central allocation will be determined by sequentially numbered. A total of 224 subjects will be randomized into four groups (SMS, Call, SMS + Call, and Control) with an allocation ratio of 1:1:1:1. SMS and calls will be sent between 48 and 72 hours before the scheduled appointment. A medical assistant will send out text messages and will call participants. Our primary outcome is appointment measured by efficacy and efficiency of interventions. We hypothesize that two reminders (concomitant use of SMS and phone calls) as an appointment reminder is more effective to improve appointment compared to one reminder (only SMS or only call), and that the most efficient is use of only SMS. The analysis will be intention to treat.
This trial investigates the potential of SMS and phone calls as motivational reminders to improve children's adherence to medical appointments for HIV-related care in Cameroon. The intervention will act to end missed appointment due to forgetfulness.Trial registration: Pan African Clinical Trials Registry: PACTR201304000528276.
[Show abstract][Hide abstract] ABSTRACT: n Cameroon, with regards to the national reprisal to human immunodeficiency virus/acquired immune
deficiency syndromes (HIV/AIDS), the HIV status of a mother delivering a live baby, when declared
unknown is always determined in the delivery room. This protocol is not applicable to women, whose
pregnancies have been identified as unproductive. A descriptive study was conducted in three public
hospitals in Yaounde from January, 2009 to February, 2012. It aimed at contributing to the reduction of
maternal and foetal mortality. A total of 14174 pregnant women were part of this study. The prevalence
rates of unproductive pregnancies were 14.9, 14.5 and 15.4% in 2009, 2010 and 2011, respectively.
Stillbirths were the most common type and elective abortions the least frequent. HIV prevalence rates
were 10.7% for women who delivered live babies and 10.5% for those who had unproductive
pregnancies. HIV was not an influential factor on the outcome of pregnancy, neither on the type of
unproductive pregnancy. Among the women with unproductive pregnancies and HIV positive status,
52.4% were unaware of their HIV status. They could have returned home in complete ignorance of their
HIV status despite their passage through a hospital. Therefore, it may be important to extend prevention
of mother-to-child HIV transmission (PMTCT) to such cases.
Journal of AIDS and HIV Research. 08/2013; 5(8):311-315.
[Show abstract][Hide abstract] ABSTRACT: HIV infection increases cardiovascular risk and highly active antiretroviral therapy may further augment it. We hypothesized that an increase in large artery stiffness may be a mechanism of enhanced cardiovascular risk in treated HIV-infected (HIV-T) patients.
Pulse wave velocity (PWV) and augmentation index (AI) were measured in 108 Cameroonian untreated HIV-infected (HIV-UT) patients and in 130 HIV-T patients.
Brachial and aortic systolic blood pressure (BP), diastolic BP, and pulse pressure were higher in HIV-T patients than in HIV-UT patients (all, P<0.01). PWV was comparable in HIV-T and HIV-UT patients (7.2±1.5 vs. 7.46±2.2 m/s, respectively, P=0.3), whereas AI was higher in HIV-T patients than in HIV-UT patients (7.9±5 vs. 5.76±4%, respectively, P=0.003). AI was associated independently with age, brachial systolic BP, brachial diastolic BP, and height in HIV patients (R=0.75, P<0.01).
This study shows that pulse pressure and AI were increased in HIV-T patients, compared with matched HIV-UT patients, suggesting that highly active antiretroviral therapy could increase cardiovascular risk. However, PWV was not accelerated in HIV-T patients.
[Show abstract][Hide abstract] ABSTRACT: Background
In low-income countries, the use of laboratory monitoring of patients taking antiretroviral therapy (ART) remains controversial in view of persistent resource constraints. The Stratall trial did not show that clinical monitoring alone was non-inferior to laboratory and clinical monitoring in terms of immunological recovery. We aimed to evaluate the costs and cost-effectiveness of the ART monitoring approaches assessed in the Stratall trial.
The randomised, controlled, non-inferiority Stratall trial was done in a decentralised setting in Cameroon. Between May 23, 2006, and Jan 31, 2008, ART-naive adults were randomly assigned (1:1) to clinical monitoring (CLIN) or viral load and CD4 cell count plus clinical monitoring (LAB) and followed up for 24 months. We calculated costs, number of life-years saved (LYS), and incremental cost-effectiveness ratios (ICERs) with data from patients who had been followed up for at least 6 months. We considered two cost scenarios in which viral load plus CD4 cell count tests cost either US$95 (scenario 1; Abbott RealTime HIV-1 assay) or $63 (scenario 2; generic assay). We compared ICERs with a WHO-recommended threshold of three times the per-person gross domestic product (GDP) for Cameroon ($3670–3800) and an alternative lower threshold of $2385 to determine cost-effectiveness. We assessed uncertainty with one-way sensitivity analyses and cost-effectiveness acceptability curves.
188 participants who underwent LAB and 197 who underwent CLIN were followed up for at least 6 months. In scenario 1, LAB increased costs by a mean of $489 (SD 430) per patient and saved 0·103 life-years compared with CLIN (ICER of $4768 [95% CI 3926–5613] per LYS). In scenario 2, the incremental mean cost of LAB was $343 (SD 425) —ie, an ICER of $3339 (2507–4173) per LYS. A combined strategy in which LAB would only be used in patients starting ART with a CD4 count of 200 cells per μL or fewer suggests that 0·120 life-years would be saved at an additional cost of $259 per patient in scenario 1 (ICER of $2167 [95% CI 1314–3020] per LYS) and $181 in scenario 2 (ICER of $1510 [692–2329] per LYS) when compared with CLIN.
Laboratory monitoring was not cost effective in 2006–10 compared with clinical monitoring when the Abbott RealTime HIV-1 assay was used according to the $3670 cost-effectiveness threshold (three times per-person GDP in Cameroon), but it might be cost effective if a generic in-house assay is used.
French National Agency for Research on AIDS and Viral Hepatitis (ANRS) and Ensemble pour une Solidarité Thérapeutique Hospitalière En Réseau (ESTHER).
The Lancet Infectious Diseases 07/2013; 13(7):577–586. · 19.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Our study in Cameroonian rural district hospitals showed that the immunologic and clinical failure criteria had poor performance to identify HIV drug-resistance in a timely manner. Switching to second-line antiretroviral therapy after two consecutive viral loads ≥5000 copies/mL, as recommended by the WHO, appeared the most appropriate strategy.
[Show abstract][Hide abstract] ABSTRACT: Introduction: The current expansion of antiretroviral treatment (ART) in the developing world without routine virological monitoring still raises concerns on the outcome of the strategy in terms of virological success and drug resistance burden. We assessed the virological outcome and drug resistance mutations in patients with 36 months' ART experience, and monitored according to the WHO public health approach in Cameroon. Methods: We consecutively recruited between 2008 and 2009 patients attending a national reference clinic in Yaoundé - Cameroon, for their routine medical visits at month 36±2. Observance data and treatment histories were extracted from medical records. Blood samples were collected for viral load (VL) testing and genotyping of drug resistance when HIV-1 RNA≥1000 copies/ml. Results: Overall, 376 HIV-1 infected adults were recruited during the study period. All, but four who received PMTCT, were ART-naïve at treatment initiation, and 371/376 (98.7%) started on a first-line regimen that included 3TC +d4T/AZT+NVP/EFV. Sixty-six (17.6%) patients experienced virological failure (VL≥1000 copies/ml) and 53 carried a resistant virus, thus representing 81.5% (53/65) of the patients who failed. Forty-two out of 53 were resistant to nucleoside and non-nucleoside reverse-transcriptase inhibitors (NRTIs+NNRTIs), one to protease inhibitors (PI) and NNRTIs, two to NRTIs only and eight to NNRTIs only. Among patients with NRTI resistance, 18/44 (40.9%) carried Thymidine Analog Mutations (TAMs), and 13/44 (29.5%) accumulated at least three NRTI resistance mutations. Observed NNRTI resistance mutations affected drugs of the regimen, essentially nevirapine and efavirenz, but several patients (10/51, 19.6%) accumulated mutations that may have compromised etravirine use. Conclusions: We observed a moderate level of virological failure after 36 months of treatment, but a high proportion of patients who failed developed drug resistance. Although we found that for the majority of patients, second-line regimens recommended in Cameroon would be still effective, accumulated resistance mutations are of concern and may compromise future treatment strategies, stressing the need for virological monitoring in resource-limited settings.
Journal of the International AIDS Society 01/2013; 16:18004. · 3.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Although treatment adherence is a major challenge in sub-Saharan Africa, it is still unknown which longitudinal patterns of adherence are the most detrimental to long-term virological response to non-nucleoside reverse transcriptase inhibitor (NNRTI) regimens. This analysis aimed to study the influence of different time patterns of adherence on virological failure after 24 months of treatment in Cameroon. METHODS: Antiretroviral therapy (ART) adherence data were collected using face-to-face questionnaires administered at months 1, 3, 6, 12, 18 and 24. Virological failure was defined as viral load >40 copies/ml at month 18 and/or 24. Two combined indicators of early adherence (months 1, 3 and 6) and adherence during the maintenance phase (months 12, 18 and 24) were designed to classify patients as always adherent during the early or maintenance phase, non-adherent at least once and having interrupted ART for >2 days at least once at any visit during either of these two phases. RESULTS: Virological failure occurred in 107 (42%) of the 254 patients included in the analysis. In the early and maintenance phases, 84% and 76%, respectively, were always adherent, 5% and 5% were non-adherent and 11% and 20% experienced ≥1 treatment interruption. Early non-adherence was independently associated with virological failure (adjusted OR 7.2 [95% CI 1.5, 34.6]), while only treatment interruptions had a significant impact on virological failure during the maintenance phase (adjusted OR 2.1 [95% CI 1.1, 4.4]). CONCLUSIONS: ART NNRTI-regimens used in sub-Saharan Africa seem to 'forgive' deviations from good adherence during the maintenance phase. Optimizing adherence in the early months of treatment remains crucial, especially in a setting of poor health care infrastructure and resources.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND:: Task shifting to nurses for antiretroviral therapy (ART) is promoted by WHO to compensate for the severe shortage of physicians in Africa. We assessed the effectiveness of task shifting from physicians to nurses in rural district hospitals in Cameroon. METHODS:: We performed a cohort study using data from the Stratall trial, designed to assess monitoring strategies in 2006-2010. ART-naive patients were followed-up for 24 months after treatment initiation. Clinical visits were performed by nurses or physicians. We assessed the associations between the consultant ratio (i.e. the ratio of the number of nurse-led visits to the number of physician-led visits) and HIV virological success, CD4 recovery, mortality, and disease progression to death or to WHO clinical stage 4 in multivariate analyses. RESULTS:: Of the 4,141 clinical visits performed in 459 patients (70.6% female, median age 37 years), a quarter was task shifted to nurses. The consultant ratio was not significantly associated with virological success (odds ratio 1.00, 95%CI 0.59-1.72, p=0.990), CD4 recovery (coefficient -3.6, 95%CI -35.6; 28.5, p=0.827), mortality (time ratio 1.39, 95%CI 0.27-7.06, p=0.693) or disease progression (time ratio 1.60, 95%CI 0.35-7.37, p=0.543). CONCLUSION:: This study brings important evidence about the comparability of ART-related outcomes between HIV models of care based on physicians or nurses in resource-limited settings. Investing in nursing resources for the management of non-complex patients should help reduce costs and patient waiting lists while freeing up physician time for the management of complex cases, for mentoring and supervision activities, as well as for other health interventions.
[Show abstract][Hide abstract] ABSTRACT: Human immunodeficiency virus (HIV) and its therapy are associated with increased aortic stiffness and metabolic syndrome (MetS) phenotype in Caucasian patients. We hypothesized that, independently of antiretroviral therapy, HIV infection in native black African patients is associated with increased burden of cardiometabolic risk factors that may accelerate arterial structural damage and translate into increased aortic stiffness.
Ninety-six apparently healthy Cameroonian subjects (controls) were compared to 108 untreated Cameroonian HIV+ patients (HIV-UT) of similar age. In each participant, pulse wave velocity (Complior), aortic augmentation index (SphygmoCor), brachial blood pressure (Omron 705 IT), fasting plasma glucose (FPG), and lipids were recorded, as well as the prevalence and severity of MetS, based on the American Heart Association/National Heart, Lung, and Blood Institute score ≥3/5.
Prevalence of impaired fasting glucose (FPG 100-125 mg · dL(-1)) and of diabetes (FPG > 125 mg · dL(-1)) was higher in HIV-UT than in controls (47% versus 27%, and 26% versus 1%, respectively; both P < 0.01). Fasting triglycerides and the atherogenic dyslipidemia ratio were significantly higher in HIV-UT than in controls. Hypertension prevalence was high and comparable in both groups (41% versus 44%, respectively; not significant). HIV-UT patients exhibited a twice-higher prevalence of MetS than controls (47% versus 21%; P = 0.02). Age- and sex-adjusted pulse wave velocity was higher in HIV-UT than in controls (7.5 ± 2.2 m/s versus 6.9 ± 1.7 m/s, respectively; P = 0.02), whereas aortic augmentation index was significantly lower (6% ± 4% versus 8% ± 7%, respectively; P = 0.01).
Similar to Caucasian populations, native Cameroonian HIV-UT patients showed a higher prevalence of MetS and its phenotype, associated with increased aortic stiffness, an early marker of atherosclerosis.
Vascular Health and Risk Management 01/2013; 9:509-16.
[Show abstract][Hide abstract] ABSTRACT: Using cohort data nested in a randomized trial conducted in Cameroon, this study aimed to investigate time trends and predictors of the susceptibility to transmitting HIV during the first 24 months of treatment.
The outcome, susceptibility to transmitting HIV, was defined as reporting inconsistent condom use and experiencing incomplete virological suppression. Mixed logistic regressions were performed to identify predictors of this outcome among 250 patients reporting to have had sexual relationships either with HIV-negative or unknown HIV status partner(s).
Despite an initial decrease from 76% at M0 to 50% at M6, the rate of inconsistent condom use significantly increased from M12 (59%) to M24 (66%) (p = 0.017). However, the proportion of patients susceptible to transmitting HIV significantly decreased over follow-up from 76% at M0, to 50% at M6, 31% at M12 and 27% at M24 (p<0.001). After controlling for age, gender and intervention group, we found that perceiving healthcare staff's readiness to listen as poor (adjusted odds ratios (AOR) [95% Confidence Interval (CI)] = 1.87 [1.01-3.46]), reporting to have sexual relationships more than once per week (AOR [95%CI] = 2.52 [1.29-4.93]), having more than one sexual partner (AOR [95%CI] = 2.53 [1.21-5.30]) and desiring a/another child (AOR [95%CI] = 2.07 [1.10-3.87]) were all associated with a higher risk of being susceptible to transmitting HIV. Conversely, time since ART initiation (AOR [95%CI] = 0.66 [0.53-0.83] for an extra 6 months and ART adherence (AOR [95%CI] = 0.33 [0.15-0.72]) were significantly associated with a lower risk of being susceptible to transmitting HIV.
The decrease observed in the susceptibility to transmitting HIV suggests that fear of behavioural disinhibition should not be a barrier to universal access to ART. However, developing adequate preventive interventions matching patients' expectations -like the desire to have children- and strengthening healthcare staff's counselling skills are urgently needed to maximize the impact of ART in slowing the HIV epidemic.
PLoS ONE 01/2013; 8(4):e62611. · 3.53 Impact Factor